Liver: Bacterial Peritonitis

Basics

• Infection of Ascitic Fluid without Intraabdominal Surgically Treatable Source
• Cause: Impaired Host Defenses
  • Deficits in Cirrhosis:
    • Phagocyte Dysfunction
    • Complement Deficiency
    • Increased Free Iron for Growth (Normally Inhibited by Unsaturated Transferrin)
  • Bacteria Seed by Translocation in Gut or From Any Infected Site

Organisms

• Usually Single Organism
• Most Common Organism: E. coli (#1), Klebsiella & Pneumococci
  • Most Common in Peds: Pneumococcal & Streptococcal
  • Most Common in Peritoneal Dialysis: S. epidermidis

Prognosis

• Overall Mortality High (20-40%)
• Best Predictors of Mortality: Renal Dysfunction & MELD Score
• Low Mortality if Treatment Initiated Early

Presentation

• Fever
• Abdominal Pain
• Diarrhea
• Cloudy Fluid Output

Diagnosis

• Dx: Paracentesis (PMN ≥ 250)
• May Also Use Fluid Cx

Treatment

• Primary Tx: Paracentesis (“Tap Until Dry”) & Cefotaxime (High Levels in Ascitic Fluid)
• Alternative ABX: Ceftriaxone or Fluoroquinolones
• Other Considerations:
  • If Renal Dysfunction Present: IV Albumin Decreases Mortality
  • Stop Nonselective Beta-Blockers (Higher Mortality Risk)
• Peritoneal Dialysis Tx: Intraperitoneal Antibiotics for 2 weeks (Better Than IV)
  • If Fails: Remove Catheter
  • Fungal Infection Requires Catheter Removal

Prophylaxis

• Indications:
  • Hx of SBP
  • Cirrhosis & GI Bleed
  • Cirrhosis, Ascitic Fluid Protein < 1.5 g/dL & Renal Impairment or Liver Failure
• ABX: Trimethoprim-Sulfamethoxazole or Fluoroquinolones (Norfloxacin)